Medical detox is considered to be the first phase of treatment in drug rehab programs. There are different clinical settings in which medical detox can occur, including but not limited to a rehab center that has a detox facility, a standalone detox facility, or a hospital. As the National Institute on Drug Abuse (NIDA) explains, detox alone is never sufficient to address the layered complexities of addiction. NIDA, in line with the addiction treatment community, always recommends that a person receives primary care services for addiction immediately after medical detox.
Understandably, some individuals may hold off on starting detox because of concerns about paying for it. In fact, according to one government-sponsored national survey, the most reported reason why people do not seek rehab services is a concern that they cannot afford them. This is one explanation for the wide gap between the number of Americans in need of drug rehab treatment and the number who actually enter rehab. A recent National Survey on Drug Use and Health estimated that while 22.7 million Americans needed drug rehab services, only about 2.5 million got help from a qualified drug rehab center.
Concerns about paying for detox, and addiction treatment in general, should never stop a person from getting help. There are options.
If a person is questioning whether health insurance will pay for detox, the short answer is that it depends on the specific insurance plan. Navigating the coverage terms of a health insurance plan, to figure out if it covers a detox program, can seem daunting. But it is important to know that there are various professionals who can help. First, the insurance company can advise clients on a plan’s coverage terms per the policy’s summary plan description. Second, once a person has selected a rehab center, an onsite benefits coordinator should be able to advise on the health insurance policy terms as they pertain to medical detox. Third, if a person does not have insurance, there are ways to get coverage.
Getting Health Insurance from an Employer or under the ACA
Individuals who do not currently have insurance may be able to get a plan that will cover the costs (all or part) of medical detox at a rehab center or other qualified facility. The key is to explore the options. First, does the person have the ability to join a family member’s employment-based plan, such as a parent (age restrictions apply) or spouse? Even if a person has the ability, there may be one major obstacle: the timing. Typically, individuals who have the right to join an employment-based health insurance plan can only do so during the open enrollment season. If there is a special qualifying event, a person may be able to join an employment-based plan under special enrollment. But note, the qualifying events are limited (e.g., a marriage). Needing drug addiction treatment, however critical, is not usually a qualifying event.
If a person in need of treatment recently had insurance coverage through a job, and very recently lost that insurance, it may be possible to look into a federal program known as COBRA (Consolidated Omnibus Budget Reconciliation Act). A person can use COBRA to extend their previous employment health insurance; however, the premiums are generally higher than those paid while employed. COBRA is not a type of health insurance; it just keeps a person in an employment group healthcare plan for an extended period of time. To learn about one’s right to COBRA, the best approach is to contact the former employer’s benefits department. For more information on COBRA, visit the official site for the US Department of Labor. A person may also be entitled to COBRA if the former health insurance came through a member of the household, such as a spouse or parent.
If it is not possible to get insurance through an employment-based plan, the Affordable Care Act (ACA) may offer a solution. The ACA opened up two main options for healthcare: private plans that are available for direct purchase by an individual and not based on employment (though some group employment plans are purchased in the Marketplace), and publicly funded plans (e.g., Medicaid). Per one research study, since the ACA went into effect, the uninsured rate in American decreased from 15.5 percent to 11.7 percent.
The ACA created the Marketplace where people can work with a trained navigator to check eligibility for different healthcare plans and learn about the costs, including the monthly premiums. This process can happen online or on the phone in most states. A navigator will start the process by taking identifying information from the applicant, including financial information. The navigator will check to see if the applicant meets the requirements of the state’s Medicaid plan. If so, this plan will be offered at no cost to the applicant. Under the ACA, all state Medicaid plans offer some level of coverage for drug recovery services, including medical detox. This is because, under the ACA, substance abuse treatment is considered an essential health benefit. As such, some form of coverage must be provided across and within all ACA plans, both private and publicly funded ones. If a person does not qualify for Medicaid, a navigator can provide information on plans with monthly premiums that can start out as low as $20 per month (this low-cost plan is called the Essential plan).
The ACA may limit enrollment in health plans to certain times of the year. For this reason, the best approach is to contact a navigator and learn about the open enrollment period for private health plans and publicly funded health plans (different enrollment rules may apply). If a person cannot obtain health insurance to cover the cost of a detox, it is not a good idea to wait for insurance. There are numerous free detox programs in various states that will accept individuals without any insurance. It’s important to know that there are always options.
Using Insurance to Pay for Detox
As noted earlier, individuals who have insurance will need to find out about the terms of coverage directly from the insurance provider. Each insurance plan maintains a summary plan description that sets forth what claims the insurance plan will cover. This document is subject to interpretation, but a plan administrator will typically be able to advise an insured person on the coverage terms for medical detox. The plan administrator should also provide information on any deductibles, copays, or other costs that the plan requires the insured to cover for medical detox. In addition, the plan may only cover a limited amount of days. As a result, the person in need of detox treatment will have to consult with the rehab center about the length of treatment.